Resident #03 hit her head during the fall on August 20th and sustained a laceration above her right eyebrow that required five sutures. She also suffered a skin tear on her right forearm that needed specialized wound treatments three times per week.
The incident occurred during what should have been a routine transfer using a Hoyer lift, a mechanical device designed to safely move residents who cannot support their own weight. CNA #236 and RN #252 were attempting to transfer the resident when the lift became stuck on the wheelchair and bed.
Instead of stopping the procedure or seeking assistance, both staff members pulled on the equipment to free it from the snag. The force caused the Hoyer lift strap to come off completely, and Resident #03 fell to the floor and struck her head.
RN #252 provided a statement dated August 20th at 2:00 P.M. confirming she had assisted with the transfer and that the lift became snagged. When staff attempted to release the equipment from the obstruction, the strap disconnected.
The Director of Nursing verified the sequence of events during a September 17th interview, stating that both staff members "believed the Hoyer lift strap disconnected after they forcefully pulling on the Hoyer lift after it became stuck."
Resident #03 required immediate medical attention. At approximately 6:30 A.M. on August 20th, RN #252 assessed her for injuries before she was transferred to the hospital for further evaluation and treatment.
The fall left lasting consequences. Nursing notes from August 25th documented new orders for ongoing wound care to treat the resident's right forearm skin tear. Staff were instructed to clean the wound with normal saline, pat it dry, and apply specialized dressings three times weekly and as needed.
After the incident, maintenance staff immediately removed the Hoyer lift from service and inspected it. They found no mechanical problems with the equipment itself.
The facility's policy on Activities of Daily Living, dated September 3rd, 2024, specifically required staff to provide proper care and services for mobility, transfers and ambulation.
Winchester Terrace implemented multiple corrective measures following the fall. On August 20th, Maintenance Director #244 completed inspections of all Hoyer lifts in the facility and identified no concerns with any of the equipment.
The Director of Nursing began conducting audits of Hoyer lift transfers, initially four times weekly for four weeks, then bi-weekly for one month, and monthly for two additional months. Documentation from August 26th through September 16th showed the audits were completed with no negative findings.
All direct care staff received re-education on safe Hoyer lift use on August 26th. Two days later, the Director of Nursing completed competency testing with all direct care staff to verify their ability to operate the lifts safely.
During September 17th interviews, CNA #230 and CNA #234 confirmed they had completed both the education and competency requirements for Hoyer lift operation.
Federal inspectors reviewed two additional resident records involving Hoyer lift transfers and found no related concerns with those cases.
The inspection was conducted in response to Complaint Number 2601158. The deficiency was classified as causing actual harm to a few residents, representing a significant safety failure in the facility's transfer procedures.
The incident highlights the critical importance of proper equipment handling during resident transfers. When mechanical lifts encounter obstacles, facility protocols typically require staff to reassess the situation, clear any obstructions safely, or seek supervisory assistance rather than applying force to stuck equipment.
Resident #03's injuries from the August fall required ongoing medical treatment extending well beyond the initial hospitalization, with wound care continuing into late August and beyond.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Winchester Terrace from 2025-09-18 including all violations, facility responses, and corrective action plans.